Abstract

Objective

To examine beliefs about the role of parenting in feeding and childhood obesity among mothers of lower socioeconomic status.

Methods

Individual semi-structured audio-taped interview with 91 mothers of preschool-aged children (49% of mothers obese, 21% of children obese) in the Midwestern United States. Participant comments were transcribed and common themes identified using the constant comparative method and NVivo software.

Results

Mothers often described their parents’ feeding style as authoritarian or neglectful, and their own current style as comparatively indulgent and better. Mothers described parents of overweight children as inept or neglectful, but never described their own parenting as such.

Conclusions and Implications

Encouraging mothers to reflect on how they were fed as children, how it may impact their current parenting, and how the relationship between mothering and child obesity is complex are important nutrition education opportunities.

INTRODUCTION

Children of lower socioeconomic status (SES) in the United States are more likely to be obese1 and interventions have limited efficacy.2–3 Parental feeding style has been the focus of a number of studies, with many demonstrating a link between restrictive feeding practices and increased risk of childhood obesity.4 General parenting style in relation to obesity risk has also been a focus of study. An authoritative style, which is characterized by high sensitivity and high expectations for self-control, has been linked with a lower risk of childhood obesity as compared to authoritarian (low sensitivity and high expectations for self control), permissive, and indulgent styles.5 Among preschoolers of lower SES, children of mothers with indulgent, as compared to authoritarian, styles, had higher body mass indices.6–7

Despite this growing literature, to our knowledge, no study has explored maternal beliefs about the role of parenting in contributing to obesity risk. Understanding how mothers of lower SES perceive their role in childhood obesity could be used to create more effective interventions tailored to these beliefs. A few prior qualitative studies have described mothers’ skepticism about definitions of childhood obesity8 and their use of food to modulate children’s behavior.8–10 The present study sought to build on this prior work by exploring both how mothers manage mealtimes, as well as how they conceptualize the role of parenting (both their own and in general) in the development of childhood obesity, with a particular focus on how mothers remembered being fed growing up. A significant amount of attention has been given in the psychology literature to how the manner in which one was mothered affects one’s own mothering behaviors.11–12 To our knowledge, however, the topic has not been addressed in the context of feeding behaviors.

METHODS

Addressing this topic requires qualitative research methodology, as well as an individual interview format, as opposed to focus groups. Discussing one’s own feelings about being parented as a child, and how it informs one’s own current parenting approach, often elicits strong emotions. In addition, discussion of perceived causes of obesity often generates strong feelings about the responsibilities of the individual (or parent) versus the community (e.g. government, schools, etc) that might not be shared in a group setting. We therefore used an individual interview approach.

The recruitment flyer invited mothers of 3- to 5-year-old children from communities of lower SES in the Midwestern United States to participate in a study of “children’s eating behavior with a parent” to help researchers learn more about “how mothers feed their children.” Inclusion criteria were that the mother spoke English or Spanish, self-identified as Hispanic, African American, or White, had less than a 4-year college degree, was the biological and custodial mother, and was healthy, and that that the child was healthy and typically developing. Mothers completed written informed consent and were compensated $40. The University of Michigan Institutional Review Board approved this study.

The mothers participated in a private, semi-structured interview (mean length = 46.6 minutes; SD = 22) with a trained interviewer. A native Spanish speaker conducted the interviews with the Hispanic mothers. Interviewers followed a standardized interview guide developed by the study authors (Table 1). The interview guide was also translated into Spanish.

Prompting questions about feeding and obesity in the semi-structured individual interview

Of 91 mothers, 32 were Hispanic, 30 African American, and 29 White; 40% had less than a high school diploma, 27% had a high school diploma only, and 33% had taken some college courses. About half (48%) of the children were male. Of the 91 dyads, 83 attended a second visit at which time weight and height were measured and child weight status was defined.13–14 Of the mothers, 49% were obese (BMI ≥30), 26% overweight (BMI ≥ 25), and 26% normal weight. Of the children, 21% were obese (BMI ≥ 95th percentile), 26% overweight (BMI ≥85th percentile), and 54% normal weight.

Interviews were digitally recorded, transcribed, and for the Spanish-language interviews, translated into English. Transcript data were systematically analyzed using the constant comparative method,15 an analytic approach in which the researcher reads each transcript, carefully noting possible themes emerging in the mother’s narrative, and constantly comparing the themes with those already identified in prior narratives. As additional transcripts are read, the researcher considers whether additional narratives fit into already identified themes, or if a new theme has emerged. The researcher begins with the identification of a large number of themes, but some are eventually discarded as not salient or coherent and some are merged as their diverse properties become integrated by a theory. The initially large number of themes is thereby reduced to those which are most coherent, salient, and saturated. This process was carried out by 3 study team members using NVivo version 7.0, (QSR International Pty Ltd, Doncaster, Victoria, Australia, 2006) and discussed over a series of group meetings. Highly concordant themes were identified. The weight status of the mother-child dyad to whom the supporting quotations were attributed was noted.

RESULTS

Three primary themes were identified and are described below.

Theme 1. Negative memories of being fed in childhood

Though some mothers shared positive memories of how they were fed as children, most mothers reported strong negative feelings about how they were fed when they were growing up, and many confidently differentiated their own approach to feeding their children from that of their parents. Mothers expressed pride that they were “doing it better than how it was done for me.” Mothers sometimes described their parents as lacking knowledge about how to prepare balanced meals and serving unhealthy foods that promoted weight gain. Other mothers stated that their parents did not spend enough time preparing foods or implied that their own mothers did not care enough about feeding them:

“My mom never really cooked like lasagna and stuff unless it was like the Stouffer’s… I learned how to cook lasagna all by myself now. And it’s so much better than Stouffer’s. But, she tried doin’ the quick and easy stuff.” (mother and child normal weight)

“Dinner, what it is with me and [my child] is nothing like it was with my family. When I was a kid we didn’t have dinners like that. Here’s a hot dog. Here’s a sandwich. Eat it. You know? It’s kinda like that. Not with me and my daughter. I make dinner. I don’t throw a hot dog at her and say, ‘ Here you go. Eat that. You’re good.’ No. I don’t do that. I just feel I wasn’ t…I wish things would have been different for me, but it wasn’t.” (mother and child obese)

Many mothers described their childhood mealtime experiences as stressful, and described their parents’ feeding style as authoritarian. The mothers implied that they felt that this approach was overly strict and insensitive, and not the appropriate way to parent around food and mealtime:

“My parents were actually very strict so dinner was somewhat stressful. We were expected to use our manners and, like, we weren’t allowed to drink while we ate… We had to clean our plates and it didn’t matter portion size, whatever, you had to eat everything that was on your plate.” (mother overweight and child normal weight)

“Our step dad was real strict with the ‘ eat everything on your plate or you’re not getting down.’ Or he would do, ‘If you’re not gonna eat everything on your plate we’ll wrap it and put it in the fridge—when you get hungry you’re not gettin’ a snack, you get dinner.’ ” (mother obese, child overweight)

Many mothers also recalled a lack of structured regular meals, and described often needing to just “fend for themselves.” The mothers implied that they valued family meals with their own children and ensured that they were incorporated into the family routine:

“My dad raised me by himself. Um, and he had a gambling problem. There was a bar just down the road. So, from like, 10 and up, um -- I don’t remember much from 10 and down -- I fed myself.” (mother obese, child weight status unknown)

“I always make sure my kids have breakfast, lunch, and dinner. My dad never did that, he, just, fend for yourself really, so, that’ s, that’s one thing I do. I make sure that they eat and I make sure that we eat together.” (mother obese, child weight status unknown)

Theme 2. Maternal emotional investment in the child enjoying the meal

In describing how they feed their children, mothers focused on serving foods that are palatable and pleasing to the child. Mothers described being proud of and confident in their ability to meet the child’s food requests and create positive affect around food and mealtime in the home. The mothers often described their emotional investment and commitment to feeding their child in a way that was in stark contrast to how they perceived being fed by their own parents:

“I almost always prepare them things that they like. Yes, because why would I make things that they are not going to eat?”(mother obese, child overweight)

Mothers often described buying only foods she knows her child will eat, preparing a second meal for the child if the child does not like what was originally served, or cooking separate meals for different members of the family based on what each person prefers:

“Well, I usually cook different meals for everybody, because everybody seems to be picky.” (mother overweight, child obese)

“Well in my house we are 4 -- my 2 children and my husband and me -- and the 4 of us eat different meals. So, I cook 4 times at once.” (mother obese, child overweight)

Many mothers voiced being deeply gratified by watching the child eat, and said that they used food to promote positive relationships with their children:

“You have to give them the best that you can, that is, with that patience because sometimes, [they say] ‘I don’t want this’ [or] ‘I…no, not this.’ [And I say to them],’ What do you want, dear? If you didn’t like the food today, what do you want?’ ” (mother obese, child overweight)

Theme 3. Attributing obesity in other people’s children to inept or neglectful parenting

The majority of mothers in this sample believed that when children are overweight, the parents are primarily at fault. Some of the strongest views about this issue came from normal weight mothers with normal weight children. These mothers tended to hold very strong and unforgiving views about the quality of parenting among other mothers. The phrase, “they don’t care” came up repeatedly from multiple mothers:

“I definitely blame overweight children on the parents. One hundred percent…I think it’s because they’re not educated, because they don’t know any better, because they’re feeding them things that are making [them] overweight and not giving them a healthy diet. Um, too much fast food. Um, a lot of parents just don’t care. I mean, honestly, there’s a lot of parents that just don’t care…Um, exercise, you know, some, parents, feed their kids fat and let them be lazy in front of the TV all day, every day. Don’t have them participating in sports. Um, I think children are overweight because of parents neglecting to do their jobs the way that they should, and [not] caring about their weight and their health.” (mother and child normal weight)

“There is people that, like the women that work a lot, sometimes can’t take care of their children and when they take care of them, they are not used to making them something to eat. Then they take them to those restaurants and I think that that makes you gain weight a lot.” (mother and child normal weight)

Many mothers voiced the belief that parents of overweight children constantly offer food to their child, or do not set limits on their child’s eating:

“I know a couple of parents who let their children eat anything all day long. And they’ll give them food just to keep them occupied, I guess. And let them eat in front of the TV all the time, so I guess I think that’s what makes them overweight, and eating a lot of fast foods.” (mother obese, child weight status unknown)

“So, I see a lot of kids that have…a lot of mothers that have heavy-set kids and they just…just because they’re hungry…they just ate two cheeseburgers…you know, just because they hungry you don’t have to feed them. And they’d say never turn down a child to eat. Yeah, I think you do. You just don’t feed your kid every time they’re hungry.” (mother and child normal weight)

The belief that childhood obesity is due to inept or neglectful parenting was equally common among mothers of obese, overweight and non-overweight children. When mothers voiced this belief, however, in every case they were referring to perceived deficits in other people’s parenting. They never described their own parenting as being a contributor, even when their own child was obese or overweight:

“[Children are overweight] if they have a parent that just lets them sit around and eat and watch TV.” (mom obese, child obese)

“The mothers give them Twinkies, candy and ice cream and – everyday, this is an everyday thing -- cookies and, you know, to me that’s what causes a child to be overweight.” (mother and child obese)

Parents of overweight or obese children were often described as modeling unhealthy lifestyles themselves, and it was implied that the parents’ own weight status was due to laziness or lack of self-discipline. These perceptions were described equally as often from obese, overweight, and non-overweight mothers, and these mothers never described their own weight status as due to these types of behaviors:

“I think that that’s really a big thing…um, parents don’t eat the right things, and the kids aren’t going to eat the right things if they don’t feed them the right things…then they’re not going to know what’s the right thing and what’s the wrong thing.” (mother obese, child weight status unknown)

“Well personally, from, like, I have friends that their kids…I always try to get them to be more active, but the parents sleep in ‘til 12, 1 o’ clock, and you know…their kids pick up the same habit. When they get up, you, know, it’s sit in front of the TV and just loungin’ all day. They don’t get up, they don’t go outside, they don’t do anything…well, if you don’t do anything with your kids and you sit in front of the TV all day, then, you know, you can’t turn around and look at your kids like why aren’t you doing something.” (mother overweight, child obese)

DISCUSSION

Several new findings emerged. First, many mothers had negative memories of how they were fed growing up, and the topic elicited strong emotion. Many of the mothers reported feeding their children in decidedly different ways from how they were fed growing up. This finding differs from previous studies that have described mothers of lower SES as strongly influenced by their own mothers’ advice about feeding.8, 10, 16–17 Findings may have differed due to characteristics of the sample or the way the interview questions were asked, but also suggest that mothers use their childhood feeding experiences as a point of reference, but often wish to distinguish their own feeding styles from those employed in their family of origin.

A second key finding emerging from these interviews was mothers’ prideful description of feeding their own child in a manner that pleased the child, and seemed to, by extension, please the mother by indicating that she was a successful, effective, and cherished parent. There was the implication that the child’s response was particularly salient for mothers who did not feel well fed or cared for themselves as children. These results are consistent with previous qualitative studies reporting that among mothers of lower SES, feeding is emotionally charged8 and often driven by children’s food preferences.9

Finally, perhaps the most surprising finding was the pervasive and strong feeling among these mothers that childhood obesity is caused by inept or neglectful parenting. This finding contrasts with that of others’ qualitative work with focus groups, reporting that mothers of lower SES believe intrinsic factors like genetics and heredity, and not parenting, are the overriding determinants of a child’s weight.8–9, 18 The emergence of the belief that parents are at fault may have occurred only in our study due to the individual private interview format.

Many of the mothers espousing this belief were discovered to have obese or overweight children themselves when the child accompanied her to be measured at the second study visit. We did not directly ask mothers during the interview if they considered their own child overweight or obese, and no mother volunteered this information. However, given that mothers often do not correctly identify their child as overweight,19 we suspect that the mothers would not have seen any conflict between their views and their own child’s weight status. We did not find evidence that some bias in the interviewer’s approach generated these responses. We can speculate that this seemingly paradoxical finding may have been rooted in two issues. First, among mothers who recognize that their own child is overweight there seems to be a fundamental attribution error. “Fundamental attribution error” is a well-recognized concept in social psychology which describes the tendency to attribute problems in oneself to things outside of one’s control, while believing that the same problem in others is due to a character flaw (i.e. thinking one’s own obesity is due to genetics, while others’ obesity is due to lack of willpower).20 Second, this significant blaming and negativity towards the parents of obese children may reflect the pervasive societal prejudice towards the obese harbored by both normal weight and obese individuals, including children.21–22

The themes identified did not directly map logically onto the list of questions asked during the interview. Mothers were allowed and encouraged to continue to talk in response to a question for as long as they wished. Some questions reliably elicited in this sample much more elaborate and involved responses than others. This pattern reflects clearly which aspects of the interview were most salient to the mothers in this sample, and underlies the generation of the identified themes. Attention to which questions in the interview elicited relatively little interest from these mothers is also hypothesis-generating and would benefit from future study.

This study has several limitations. There was some loss to follow up for the second study visit, which led to some missing data for children’s weight status. The results may also only be applicable to mothers of lower SES who are particularly interested in the topic of children’s eating behavior and how parents feed their children, given how the study was advertised. Mothers with less interest in this topic may not have as strong feelings about how they were fed as children, may be less invested in their child enjoying the meal, and may have less strong feelings about others’ parenting skills around food. In addition, though the mothers in this study referred to “parenting” in their narratives, there may be unique roles for mothers and fathers, and additional work with fathers is warranted. Finally, these data were not analyzed in a manner to allow comparison of the prevalence of themes across racial/ethnic groups. This is an area which deserves consideration in future work.

Our study also, however, had several strengths. While prior studies have conceptualized parenting using questionnaires or standardized videotaped interactions,4–7 our study used a semi-structured interview format that may have provided data unique from these other methodologies. The nature of the interview format allows a greater focus on the ‘how’ and ‘why’ of mothers’ behaviors and beliefs, as opposed to only the ‘what’, which is typically the focus of the other methodologies.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Mothers’ strong feelings about how they were fed growing up may be relevant to intervention development in several ways. First, for most of these mothers, criticism of their own parents’ feeding style was rooted in a recognition that it was flawed or ineffective, particularly in the context of modern nutrition knowledge. This thoughtful critique of how they were parented might be viewed as a strength: the mother could be praised for the ways she is “doing it better” and at minimum, a conversation about feeding style might be opened with the acknowledgement that she has given the issue significant thought, lending credence to the mother’s own opinions and perhaps how they were generated. Secondly, however, in some cases mothers’ strong affect around the perceived inadequacies of how they were fed growing up may lead to maladaptive feeding practices. For example, some mothers may be less motivated to encourage new foods and expand dietary variety because it generates conflict at the dinner table. If the mother is unable to effectively cope with the child’s behavior, she may feel like a less effective parent or even unloved by the child. In her effort to prevent these feelings, she may simply avoid the situation altogether by presenting only palatable foods. The nutrition interventionist might serve the role of first suggesting this dynamic to the mother, in empathic, simple and non-threatening terms. It is not clear that separating maternal affect from feeding is desirable, appropriate, or even achievable, but when that affect may be contributing to obesity-promoting feeding practices, acknowledgement of the role affect may be playing in feeding may be the first step towards changing the dynamic. Ultimately, these types of dynamics may be best addressed for some women in the context of an ongoing relationship with a mental health professional.

The second primary implication of these findings for practice regards mothers’ belief that children are obese due to inept or neglectful parenting, which may contribute to their rejection of the diagnosis in their own child – mothers may simply not be able to reconcile the idea that their own child could be obese when they view their own parenting as loving, attentive, and competent. Clinicians might find it effective to discuss with mothers that in today’s obesity-promoting environment, a higher degree of parental authority is likely now needed. Parents who practice ‘usual’ good parenting, but have not adapted to the changing environment to exert more control in regulating the child’s access to obesity promoting foods and pastimes, are likely putting their child at risk. Helping mothers to recognize that the causes of obesity in children are multi-factorial, complex, and occurring at levels often outside the scope of an individual mother’s power may be the first step towards allowing mothers to accept that their own child is obese or overweight. Finally, it may also be useful to introduce the possibility that their punishing views of parents of obese children may have developed unintentionally in response to the pervasive societal prejudice against obese individuals. If the mother is able to release some of her blaming and negativity, she may be better able to accept that her own child is obese or overweight and to incorporate some changes into her parenting style.

A third primary implication of these findings regards the theme that mothers often recalled their own upbringing around food as neglectful or authoritarian, and often described their own approach to feeding their child as indulgent. This indulgent style often seemed reactionary to the comparatively insensitive, strict, or inattentive style of their own childhood. Studies to date suggest that all of these styles are associated with increased obesity risk as compared to an authoritative style characterized by high sensitivity and high expectations for self-control.5–7 Mothers should be applauded for their sensitive feeding style, particularly in comparison to how they were raised. However, mothers might also be introduced to the idea that one can be a very sensitive parent while also teaching the child to adhere to rules and structure. In short, promoting an authoritative parenting style may be one important strategy for childhood obesity prevention.

In summary, the results highlight the need to develop obesity interventions well-informed by the affective context in which feeding occurs, and to recognize that how a mother feels about herself as a parent will be critical to her ability to implement recommendations for behavioral change.

Acknowledgments

Funding Source: McKay Cardiovascular Research Center Grant and Michigan Diabetes Research and Training Center Pilot and Feasibility Grant to Dr. Lumeng Approved by the University of Michigan Institutional Review Board.

This study was supported by the McKay Cardiovascular Research Pilot Grant and the Michigan Diabetes Research and Training Center Pilot and Feasibility Grant funded by DK020572 from the National Institute of Diabetes and Digestive and Kidney Diseases, both to Dr. Lumeng.

Footnotes

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